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Better and safer surgical careVictorian Audit of Surgical Mortality-Advancement in the Surgical Safety Frontier
February 2020
Vision: Outstanding healthcare for all Victorians. Always.
Our purpose: To enable all health services to deliver safe, high-quality care and experiences for patients, carers and staff.
Our values: Challenge the norm; Accept nothing less than excellence; Tell it like it is; One team; Bring your whole self
Our aim: To improve health care across Victoria so it is safer, more effective & person-centred by 30th June 2023
ImprovementMonitoring
and Assurance
LeadershipPartnership
and Planning
How will do this?
Strategic approach to quality management
Better and safer surgical care
SCV Quality Management System
Safer Care Victoria - High Level Structure
6
Chief Executive Officer
Euan Wallace
Deputy CEO / Chief Nurse and Midwifery
Officer
Ann Maree Keenan
Director - Strategy and Operations
Partner
Robyn Hudson
Director –Improvement Partner
Nicole Brady
Director - System Safety Partner
Helen Rizzoli
Director - Centre of Patient Safety and
Experience
Louise McKinlay
Director - Centres of Clinical Excellence
Rebecca Power
Executive Assistant
Safer Care Victoria - Centre of Patient Safety and Experience Overview
7
Director
Centre of
Patient Safety and Experience
Secretariat Clinical Councils and Voluntary Assisted Dying
Patient Experience and Response
Patient Safety Review
Safer Care Victoria - System Safety Partner Overview
8
Director
System Safety Partner
System PerformanceSector Development
and CapabilityQuality & Safety
Analytics
Sentinel Event Report 2018/19
Category of sentinel events notified
2018–19
Of the 121 sentinel events notified in 2018–19, 86 (71 %) resulted in death
of the patient..
More consumers on RCA review panels, representing the patient and family voice (33%, up from 17% in 2017-18)
More external experts on RCA panels bringing an independent viewpoint (85% up from 80% in 2017-18)
More people trained in RCA review methods (662, up from 150 in 2017-18)
More recommendations made to improve systems of care (603, up from 466 in 2017-18)
More health services have reported on their progress in implementing improvement (recommendations) arising from RCA reviews (53%, up from 35% in 2017-18 and 3% in 2016-17)
Category 10–11
11–12
12–13
13–14
14–15
15–16
16–17
17–18
18-19
1 Procedures involving the wrong patient or body part resulting in death or major permanent loss of function
1 1 0 0 0 0 1 1 1
2 Suicide of a patient in an inpatient unit 9 8 9 8 4 7 7 7 5
3 Retained (un-retrieved) instruments or other material after surgery requiring re-operation or further surgical procedure
5 7 6 6 6 7 7 12 10
4 Intravascular gas embolism resulting in death or neurological damage
1 0 0 1 0 1 2 0 1
5 Haemolytic blood transfusion reaction resulting from incompatibility
1 0 0 0 0 0 0 2 0
6 Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs
2 4 1 3 7 1 3 2 5
7 Maternal death associated with pregnancy, birth and the puerperium
2 0 1 3 2 0 3 0 0
8 Infant discharged to the wrong family 0 0 0 0 0 0 0 0 0
9 Other catastrophic: ISR1 37 21 17 33 23 31 49 98 99
Total 58 41 34 54 42 47 72 122 121
Breakdown of Category 9 (Vic Only) 2018/19
38
19
17
8
6
5
2 4
Clinical process/procedure
Deteriorating patient
Falls
Behaviour
Medication/intravenous fluids
Clinical administration
Nutrition
Medical device/equipment
Released revised Sentinel Event Criteria - in effect since July 2019
Revised the Incident Management Policy – now known as the Adverse Patient Safety Event Policy (August 2019)
Released guidance pertaining to Victoria’s ‘other’ category (was cat 9 now cat 11)
Year ahead:
Releasing new tools and factsheets to assist with reviews
Developed new training products in different methods
Our Work at SCV 2019/20
1. Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death
2. Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death
3. Wrong surgical or other procedure performed on a patient resulting in serious harm or death
4. Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death
5. Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death
6. Suspected suicide of a patient in an acute psychiatric ward
7. Medication error resulting in serious harm or death
8. Use of physical or mechanical restraint resulting in serious harm or death
9. Discharge or release of an infant or child to an unauthorised person
10. Use of an incorrectly positioned oro- or naso-gastric tube resulting in serious harm or death
New sentinel event categories from 1 July 2019
Aim:
To identify the extent of patient harm relating to:
• Anticoagulation Therapies
• Bowel perforations from colonoscopies
Method:
• Identify and collate relevant data.
• Establish partnerships with sector groups to guide the projects and assist with data
interpretation.
Intended Outcome:
• Produce a scoping report that identifies high level patterns and/or themes from the data. This
will guide future work in this space within SCV and the sector.
Complications vs Harm? SCV Scoping Projects:
Sharing of protected information for quality and safety purpose
17
• monitoring and review of quality and safety of health services
and associated risk
• reporting to the Secretary or a
quality and safety body about:
– performance of health service
– risk to an individual or community associated with performance of health service
• incident and performance reporting
• incident response, including case review.
Just and Learning Culture
Mistakes result from bad systems- not bad people
Every system is perfectly designed to deliver the results it gets
Just culture
Trust, learning and accountability
People are not punished for actions, omissions or decisions taken by them which are in line with their experience and training,
but gross negligence, wilful violations and destructive acts are not tolerated.
“…some prominent leaders began to
question the singular embrace of the
‘no blame’ paradigm … describing the
need for a more aggressive approach
to poorly performing practitioners”
Wachter & Pronovost in NEJM 2009
“…increasing disquiet at how the
importance of individual conduct,
performance and responsibility was written
out of the safety story. [We now] need to
take seriously the performance and behaviours of individuals”
Shoiania & Dixon-Woods in BMJ 2009
Implications for review
• Hunting for a broken component
• Looking for a root cause
• Looking for failures, inadequacies, poor decision
making, judgement errors etc
• Not looking at interactions
Not to assign blame to any individual
To identify how factors across the system combine to create accidents and incidents
Goal
Common flaws
Principles to help improve surgical safety frontier
1. Keep focus on learning2. Manage your bias3. Focus on system
improvement 4. Use a just culture lens
Questions
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